The Royal Australian and New Zealand College of Ophthalmologists
Recommendations from the Royal Australian & New Zealand College of Ophthalmologists on visual fields, vitamins, alpha-1 blockers, intravitreal injections & retinal detachment. The Royal Australian and New Zealand College of Ophthalmologists (RANZCO) is the leading medical eye specialist organisation in Australia and New Zealand. RANZCO’s mission is to drive improvements in eye health care through continuing exceptional training, education, research and advocacy.
Intravitreal injections may be safely performed on an outpatient basis. Don't perform routine intravitreal injections in a hospital or day surgery setting unless there is a valid clinical indication.
Studies show that giving intravitreal injections, most commonly anti-VEGF agents for “wet” macular degeneration, can be safely done in an outpatient setting if standard, well published protocols are followed. These protocols include the use of standard aseptic technique, topical antiseptic in the conjunctival sac, and a face mask. Performing these injections in a hospital or day surgery adds enormous cost to the procedure for no clinical benefit. This cost, initially borne by private health funds, clearly puts pressure on the sustainability of the private health system and contributes to the need to increase health insurance premiums and to reduce benefits for other procedures.
- Shimada H, Hattori T, Mori R, Nakashizuka H, Fujita K, Yuzawa M. Minimizing the endophthalmitis rate following intravitreal injections using 0.25% povidone-iodine irrigation and surgical mask. Graefe's Archive for Clinical and Experimental Ophthalmology 2013;251(8):1885-90.
- Tabandeh H, Boscia F, Sborgia A, Ciraci L, Dayani P, Mariotti C, et al. Endophthalmitis associated with intravitreal injections: office-based setting and operating room setting. Retina 2014;34(1):18-23.
- Merani R, Hunyor AP. Endophthalmitis following intravitreal anti-vascular endothelial growth factor (VEGF) injection: a comprehensive review. International Journal of Retina and Vitreous [Internet] 2015; 1(9).
- Fagan XJ, Al-Qureshi S. Intravitreal injections: a review of the evidence for best practice. Clinical & Experimental Ophthalmology 2013;41(5):500-7.
- The Royal Australian and New Zealand College of Ophthalmologists. Guidelines for performing intravitreal therapy 2006/2012. Available from: http://www.ranzco.edu/images/documents/policies/CPG004_Intravitreal_Injections.pdf.
RANZCO has undertaken a multi-stage consultation process to ensure that the entire spectrum of medical eye specialists in Australia and New Zealand can contribute to the process of identifying and refining the top five recommendations. The first stage included a survey of fellows to identify possible recommendations, which were then narrowed down and by a dedicated “Choosing Wisely” committee of RANZCO members. A second survey was then sent to all members to provide feedback on the list of five and received a high response rate. Based on the extensive feedback received via the survey, RANZCO’s “Choosing Wisely” committee crafted the final wording of the top five recommendations. Finally, the RANZCO board discussed and approved the recommendations.
- 1 In the absence of relevant history, symptoms and signs, ‘routine’ automated visual fields and optical coherence tomography are not indicated.
- 2 AREDS-based vitamin supplements only have a proven benefit for patients with certain subtypes of age-related macular degeneration. There is no evidence to prescribe these supplements for other retinal conditions, or for patients with no retinal disease.
- 3 Don't prescribe tamsulosin or other alpha-1 adrenergic blockers without first asking the patient about a history of cataract or impending cataract surgery.
- 4 Intravitreal injections may be safely performed on an outpatient basis. Don't perform routine intravitreal injections in a hospital or day surgery setting unless there is a valid clinical indication.
- 5 In general there is no indication to perform prophylactic retinal laser or cryotherapy to asymptomatic conditions such as lattice degeneration (with or without atrophic holes), for which there is no proven benefit.
- 6 Do not use corneal cross linking for every patient with keratoconus.
- 7 Do not use topical antibiotics pre or post intravitreal injections.
- 8 Do not investigate systemically well patients with a first, uncomplicated episode of acute anterior uveitis.
- 9 Topical steroids should not be used unless infection has been ruled out in any patient with red eye.